Disparities/Minority Health

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Studies suggest that ethnic differences in use of knee replacement surgery are linked to patient expectations and preferences

Blacks and Hispanics are less likely than whites to undergo total knee arthroplasty (TKA) for knee osteoarthritis in order to relieve pain and improve functioning. This difference is not entirely explained by ethnic differences in prevalence, severity of the condition, or access to care. There is some evidence to suggest that ethnic variation in the use of TKA may be related to pain perception and expectations for the procedure, according to two studies supported by the Agency for Healthcare Research and Quality. The first AHRQ-supported study (HS10389) reveals higher levels of pain with knee osteoarthritis among blacks, which may be related to negative expectations of pain-related outcomes and their relatively low preferences for TKA. A second AHRQ-supported study (HS10876) finds that blacks perceive fewer differences between mild and severe osteoarthritis states than whites, and possibly are less willing to make tradeoffs such as undergoing TKA. Both studies are summarized here.

The authors of this study reviewed the research literature to examine two factors relevant to the pain associated with knee osteoarthritis (OA): pain-related beliefs and ethnic variations in these beliefs, including expectations of the outcome of TKA. Several studies indicated that some people "catastrophize" pain—that is, they tend to focus on and exaggerate the threat posed by painful stimuli and to negatively evaluate their ability to cope with pain. Among patients with knee OA, relatively high levels of catastrophizing were associated with higher clinical pain ratings and lower pain threshold and tolerance.

The work of these authors and that of other researchers indicates that, compared to whites, blacks tend to report higher levels of catastrophizing and pain-related affect in both clinical and laboratory-based settings. Two recent studies found that blacks had significantly more negative expectations than whites on pain-related outcomes such as postsurgical pain, walking ability, length of hospital stay, and unintended consequences (for example, persistent pain and death). These findings suggest that the lower incidence of blacks undergoing knee or hip arthroplasty when compared to whites may be related to differences in patients' expectations.

The authors believe these findings are related to the relatively lower preference for TKA among blacks. They have begun work on a video about TKA for blacks to study the benefit of emphasizing the losses that are likely to occur if the surgical procedure is refused. This is in contrast to positive-framing messages that emphasize the likely benefits of the procedure.

According to this study, people with osteoarthritis (OA) perceive the condition as worse than people without OA. Also, blacks are more likely to perceive the condition as better than whites do, and blacks are less inclined to make tradeoffs (such as TKA) to improve their health. Researchers used 3 techniques during interviews—visual analog scales (VAS), time trade-off (TTO), and standard gamble (SG)—to ascertain how 198 white, black, and Hispanic patients with knee OA and 193 people in the community without the condition viewed mild and severe OA. VAS scores indicated how the participants would feel living with arthritis for the rest of their lives. The SG scale measured participants' preferences for either living with arthritis or undergoing a treatment that had varying chances of perfect health or death. TTO measured participants' preferences for living with arthritis for the rest of their life expectancy or living in perfect health for a shorter life span which was varied between 0 and their life expectancy. Preferences were scored on a scale from 0 to 100.

The researchers defined severe OA to include problems walking, problems with self-care, problems performing daily activities, extreme pain or discomfort, and moderate anxiety and depression. Mild arthritis included problems walking, no problems with self-care, no problems performing daily activities, moderate pain or discomfort, and no anxiety or depression.

Blacks gave higher scores, or a higher preference, to more severe states (having more serious problems) than whites using both the TTO and SG methods. Blacks also had significantly smaller differences in preferences between the severe and mild states of OA by the TTO and SG. These results suggest that blacks were less willing to make tradeoffs to improve their OA. The researchers conclude that some of the ethnic variation in arthroplasty rates may be determined by lower willingness to undergo the procedure among black than white patients.